Predictors of compartment syndrome of the foot after fracture of the calcaneus

Risk factor of postoperative incision infection after plate internal fixation of calcaneal fractures: a retrospective study

BACKGROUND

This study aimed to investigate the risk factors for incision infection after plate internal fixation for calcaneal fractures by a traditional lateral L-shaped approach.

METHODS

The clinical data of 302 patients with calcaneal fractures who underwent surgical treatment in our hospital from January 2012 to June 2018 were retrospectively analysed, consisting of 177 males and 125 females. The enrolled patients were aged 21 to 75 years, with a mean age of 47.72 years. According to the Sanders classification, 108 patients were type II, 138 patients were type III, and 56 cases were type IV. A univariate analysis was conducted with sex, age, smoking history, history of diabetes, cause of injury, Sanders type, tension blisters, time from injury to surgery, preoperative haemoglobin, preoperative albumin, operation time, and bone grafting as possible risk factors. The factors with statistically significant differences were selected for multivariate binary logistic regression analysis. The clinical cut-off values of these risk factors were calculated using characteristic curves.

RESULTS

The follow-up lasted for at least 1 year for all patients, with a mean follow-up time of 15.8 months. The results demonstrated 7.9% (24/302) infection rate after plate internal fixation of calcaneal fractures by the traditional lateral L-shaped approach. Univariate analysis showed that a history of diabetes, preoperative albumin, preoperative haemoglobin, time from injury to surgery, and operation time were correlated with incision infection (p < 0.05). Additionally, multivariate regression analysis indicated that a shorter time from injury to surgery (OR = 1.475, 95% CI: 1.024-2.125, p = 0.037), lower preoperative albumin (OR = 1.559, 95% CI: 1.191-2.041, p = 0.001), and longer operation time (OR = 1.511, 95% CI: 1.219-1.874, p < 0.001) were risk factors for postoperative incision infection, and their cut-off values were 10.5 days, 38.5 g/L, and 84.5 minutes, respectively.

CONCLUSION

Longer preoperative stay and operation time were two risk factors for postoperative incision infection. However, lower preoperative albumin level is the highest risk factor in this study.

TRIAL REGISTRATION

The trial was registered in the China Clinical Trial Registry (ChiCTR2100047038).

Complications in the Management of Displaced Intra-articular Calcaneal Fractures: A Systematic Review and Network Meta-Analysis of 2538 Patients

The purpose of this study was to compare the complication risk of different treatments for displaced intra-articular calcaneal fractures (DIACFs). Randomized controlled trials comparing interventions for DIACFs were included: (1) interventions with conservative treatment, surgery with a minimally invasive approach (MIA) (sinus tarsi or small longitudinal), surgery with a percutaneous approach (PA) and open surgery with the extensive "L" lateral approach (ELA), and (2) complications and wound infections were also assessed. Twenty-six published trials met the inclusion criteria. The trials involved a total of 2538 patients surgically treated for acute DIACFs. For total complications, the mean incidence rate in the ELA was significantly higher than the rates in other treatments (conservative treatment vs ELA: odds ratio (OR), 0.36; p < .001; MIA vs ELA: OR, 0.23; p = .002; and PA vs ELA: OR, 0.18; p < .001). For wound infections, there were no significant differences among the groups (MIA vs PA: OR, 0.98; 95% CI, 0.32-3.01; p = .977; MIA vs ELA: OR, 0.45; 95% CI, 0.19-1.10; p = .081; and PA vs ELA: OR, 0.46; 95% CI, 0.19-1.11; p = .085). According to the surface under the cumulative ranking curve, the PA was most likely to be the best management for minimizing complications (surface under the cumulative ranking curve = 86.2). The ELA was significantly related to a higher risk of complications among all management methods. The PA was most likely to be the ideal choice when only complications were considered.

Compartment Syndrome of the Foot

Foot compartment syndrome is an uncommon condition that should be recognized by all orthopedic surgeons. The clinical presentation is often less clear than other limb compartment syndromes and requires high clinical suspicion with a low threshold for direct measurement of compartment pressure. Controversy exists regarding the number of anatomic compartments and the most effective treatment. Both acute surgical intervention and delayed management can result in significant morbidity and long-term sequelae.

Calcaneal Fractures-Which Approach for Which Fracture?

Treatment of calcaneal fractures has to be tailored to the individual pathoanatomy. If operative treatment is chosen, anatomic reconstruction of the calcaneal shape and joint surfaces is mandatory. For most of the displaced, intraarticular fractures, this can be achieved by less invasive reduction and fixation via a sinus tarsi approach, which may be extended along the "lateral utility" line for calcaneocuboid joint involvement or calcaneal fracture-dislocations. Purely percutaneous fixation is the treatment of choice for displaced extraarticular fractures and simple intraarticular fractures with adequate control of joint reduction. Specific approaches are used for rare calcaneal fracture variants.

Regional anesthesia and acute compartment syndrome: principles for practice

Acute compartment syndrome (ACS) is a potentially reversible orthopedic surgical emergency leading to tissue ischemia and ultimately cell death. Diagnosis of ACS can be challenging, as neither clinical symptoms nor signs are sufficiently sensitive. The cardinal symptom associated with ACS is pain reported in excess of what would otherwise be expected for the underlying injury, and not reasonably managed by opioid-based analgesia. Regional anesthesia (RA) techniques are traditionally discouraged in clinical settings where the development of ACS is a concern as sensory and motor nerve blockade may mask symptoms and signs of ACS. This Education article addresses the most common trauma and elective orthopedic surgical procedures in adults with a view towards assessing their respective risk of ACS and offering suggestions regarding the suitability of RA for each type of surgery.

Distraction subtalar arthrodesis for calcaneal malunion

Aims

We hypothesized that there is no difference in the clinical and radiological outcomes using local bone graft versus iliac graft for subtalar distraction arthrodesis in patients with calcaneal malunion. In addition, using local bone graft negates the donor site morbidity.

Patients and Methods

We prospectively studied 28 calcaneal malunion patients (the study group) who were managed by subtalar distraction arthrodesis using local calcaneal bone graft. The study group included 16 male and 12 female patients. The median age was 37.5 years (interquartile range (IQR) 29 to 43). The outcome of the study group was compared with a control group of ten patients previously managed by subtalar distraction arthrodesis using iliac bone graft. The control group included six male and four female patients. The median age was 41.5 years (IQR 36 to 44).

Results

The mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score improved significantly in the study and the control groups (p < 0.001). Fusion was achieved in 27 patients in the study group at a median time of 13 weeks (IQR 12 to 14), while all the patients in the control group achieved fusion at a mean time of 13.2 weeks (11 to 15). The mean talocalcaneal height and talar declination angle improved significantly in both the study and the control groups (p < 0.001). There was no significant difference between both groups concerning the preoperative or the postoperative clinical and radiological measurements. Donor site morbidity was reported in four out of ten patients in the control group.

Conclusion

Local calcaneal bone graft can successfully be used to achieve subtalar distraction arthrodesis with appropriate correction of alignment and calcaneal malunion. We recommend using local instead of iliac bone graft as it gave comparable results and avoids the possibility of donor site morbidity. Cite this article: Bone Joint J 2019;101-B:596–602.

Clinical Management of Acute, Closed Displaced Intra-Articular Calcaneal Fractures

Performing a thorough clinical evaluation following an acute displaced intra-articular calcaneal fracture is paramount for optimal surgical timing and long-term outcome. Initial survey must entail a comprehensive evaluation to rule out concurrent injuries. Focused lower extremity examination must involve a complete neurovascular and soft tissue evaluation to identify such conditions as compartment syndrome or compromised integument, which necessitate urgent intervention. Establishing baseline radiographs and advanced imaging is vital for surgical planning. Once deemed stable, protocol-driven treatment is best to ensure proper control of pain and edema and adequate management of economic and patient safety concerns.